Responding to domestic abuse in an NHS trust

Summary

Mental health services are recognised to have an important role in responding to domestic abuse, but approach across the UK's National Health Service (NHS) is inconsistent. We describe an example of taking a whole- organisation approach to responding to domestic abuse in one NHS mental health foundation trust.

Domestic abuse is a major public health issue; the health impacts are wide-ranging and profound and a significant cause of avoidable morbidity and mortality (World Health Organization 2013; National Institute for Health and Care Excellence (NICE) 2016). In an article in this journal, Wilson considers the opportunities for learning from innovation in healthcare responses to domestic abuse during the COVID-19 pandemic (Wilson 2022). As she describes, those accessing mental health services are known to be disproportionately affected, in terms of both past experiences of harm and further victimisation (Khalifeh 2015). Mental health services therefore have a vital role in identifying and responding to domestic abuse. Despite this knowledge, national guidance and policy (Department of Health 2003; NICE 2016), ‘routine enquiry’, standards of data collection and commissioning of pathways for appropriate and timely specialist support (in both the National Health Service (NHS) and third-sector provision) are poorly and inconsistently embedded. We describe below how an NHS mental health trust, consistently recognised as a site of best practice (Standing Together 2020), continues to develop and embed innovative and evidence-based practice through a whole-organisation response.

Camden and Islington NHS Foundation Trust

Camden and Islington NHS Foundation Trust (C&I) serves a diverse inner-London population. It has a history of leading good practice in response to domestic abuse, with provision of a women-only acute crisis house developed on trauma-informed principles, a Women's Strategy Group, the foundation of which is women with lived experience, and a funded women's lead post to promote women's issues in all mental health settings.

Organisational structure

In view of this reputation, in 2015, funded by the Department of Health, C&I partnered with the charity Against Violence and Abuse (AVA) to embed a structured response to domestic and sexual abuse (DSA) through the development of the Awareness and Response to Domestic and Sexual Abuse (AR-DSA) network. This network continues to work closely with the safeguarding team, Women's Strategy Group and local DSA partners to maintain a robust DSA policy and staff training programme and to support the work of both AR-DSA ‘champions’ and co-located independent domestic and sexual violence advocates (IDSVAs) across the trust. In addition to core training, regular events run to promote awareness, build connections and increase workforce skills (e.g. annual White Ribbon Events and webinars covering subjects such as female genital mutilation, so-called honour-based violence and responding to perpetrators).

As recommended for organisations supporting individuals with multiple disadvantages (NHS England 2019), in February 2020 the C&I board made a commitment to becoming a trauma-informed organisation (TIO) and endorsed a trauma-informed approach in its clinical strategy (2020–2024). A TIO recognises and acknowledges the impact of childhood adversity, trauma in adults and wider systemic inequality on the development of mental health problems. It seeks to create conditions that reduce harm and promote healing, especially for individuals who have already experienced trauma. It embeds guiding principles of choice, collaboration, empowerment, safety, transparency (and in the C&I model, equity) and recognises that change throughout the whole organisation, not just in clinical services, is needed to embed this cultural change (Fallot 2015). Trauma leads, alongside a board champion, have developed strategy to embed and measure change throughout the organisation.

Strengthening safeguarding policy and practice

In 2019 C&I was one of eight NHS pilot sites to participate in the national Pathfinder Project, a shared vision to achieve best practice responses to domestic abuse in a healthcare setting. The governance from this project strengthened local partnerships, and funding allowed two IDSVA co-location posts in the mental health trust, which through joint working increased the identification of support for survivors of abuse and improved their access to it. This led to the development of the ‘safeguarding domestic abuse’ practitioner role to integrate guidance and research into practice, such as raising awareness, knowledge and confidence of trust staff in relation to domestic and sexual abuse through training, case consultations and supervision, enhancing the quality of care that individuals receive. This post meets the recommendations of best practice outlined in the statutory guidance issued under the Domestic Abuse Act 2021 (Home Office 2019).

NHS trusts are required to have a named doctor only for safeguarding children, but in C&I funding was agreed to appoint a named doctor for adult safeguarding to support a full multidisciplinary team approach.

Developing the workforce

Training and developing staff is essential. A stepped approach to training has been developed within our organisation to progress knowledge. Mandatory e-learning on trauma-informed approaches must be undertaken by all clinical staff, the domestic abuse content of mandatory level 3 safeguarding training has been expanded and AR-DSA champions are recommended to undertake more thorough training with specialist partners (e.g. domestic abuse ambassador training with ‘UK Says No More’). The regular mandatory all-staff training events update staff on best practice, carefully considering the diverse issues for the communities served in the local population. Clinical resources are developed to support front-line practice, such as the DSA safety planning and support sheet for front-line staff (Camden and Islington NHS Foundation Trust 2020).

Data collection and recording

To improve data collection and support staff in their duty of routine enquiry, changes have been made to the trust's risk assessment tool to facilitate early identification of survivors and alleged perpetrators. The changes aim to encourage the use of sensitive language and strengthen staff confidence in safeguarding decisions and sharing information. In addition, new mandatory fields mean that data are now routinely collected and will be reviewed to measure change and consider areas for further learning.

Policy for staff and those using services

Domestic abuse can affect us all and at C&I the DSA policy reflects this awareness and includes responding to patients, staff, visitors and carers. Working with the trust's well-being team, pathways to support for staff experiencing domestic abuse have been reviewed. A poster campaign (developed with permission from original work undertaken at Black Country Healthcare NHS Foundation Trust) supported the launch and raising awareness.

Evaluation and ongoing learning

As trauma leads for C&I we recognise the need to embed whole-culture change and ongoing learning. Our improved data systems, internal structures and governance will enable us to more effectively measure outcome and change and drive improvements in practice and response.

We hope that this article serves as an example of how NHS trusts can really start to embed the change needed to address this devastating public health issue and make the case for much needed national standards of practice, mandatory data collection and consistent commissioning of clear pathways of support for victims/survivors through partnership working across the health, social care and third-sector landscape.